Wednesday, September 8, 2010

To Induce or Not to Induce?

Tegan Vanden Bosch

It was my ten-week pregnancy check up. Being the nervous new-to-be mother, I had a lot of questions for my OB when I went to my appointment. One of many questions asked, and answered, was as follows: “So at what point in the pregnancy do we start talking about the labor and delivery process?” I was just curious, I looking for answer akin to “Oh, about 30 or 35 weeks”. I’m a planner; I just wanted a time-line for myself to mentally prepare for every step in the pregnancy and birthing process. Instead I got something quite different. “Well, we’ll probably induce you at thirty-eight weeks, most likely on a Thursday.” What?!? Induction? What in the world for??? “I don’t really believe in being induced for a non-medically necessary reason . . .” I started timidly, completely taken for surprise. I hadn’t really been prepared to defend myself in such a manner at this point in my pregnancy. In a very brisk, business-like manner, the doctor replied “It really is best, that way your husband will know ahead of time and can get off work (she nodded her head to my husband who was sitting in the chair next to the exam table), you’ll be able to get a full night’s rest before the baby comes . . .” and she continued to rattle off another half dozen or so reasons of why she wanted to induce me. I couldn’t believe it, and at the same time that I was forming an argument in my head for every single reason, I felt powerless to respond. I felt as though my beliefs had just been trampled upon. From previous visits and conversations with this doctor, I knew that she and I stood on the same ground on many issues including contraception, natural family planning and God’s presence in the entire process of marital bliss, including conception. And here she was telling me she was going to induce me? I was only ten weeks pregnant; I wasn’t carrying twins, I didn’t have two uteruses or a uterus with a septum, I didn’t have any reason for being high risk and needing to have my labor induced. This OB had delivered three of my good friend’s babies and they all were able to have completely natural labors (without ever mentioning induction). Why did she suddenly say she wanted to induce me? Why didn’t she listen to what I wanted to say about being induced? Aren’t I the one who will have to carry and birth this baby and live with the choices and decisions and consequent life long memories, not her? I left her office that day stunned, disappointed, ignored and bewildered. I knew that I had a lot to think about. My attributing factor to this news was that she had recently moved into a solo practice, away from a group practice. In a group practice, an OB is freed from being on call twenty-four/seven; an OB in solo practice doesn’t have that luxury. So for strictly business reasons of pure convenience, it is not unusual for an OB in solo practice to try to schedule as many inductions as possible, whether they are medically necessary or not. I am not saying I am against inducing women into labor; there are certainly a number of reasons where a woman should be induced for her safety and/or the safety of her child. For example, preeclampsia or eclampsia (where the mother’s blood pressure is extremely high due to the baby), if the baby has had their first bowel movement prior to the water breaking and/or prior to being born, being two weeks past the due date (greater than 42 weeks), and the list of reasons goes on. For the purpose of this paper, I would like to explore medical induction of labor and the reasons for and against doing so. Personally, I think that a healthy baby being born to a healthy mother should be able to arrive in their own time and that the convenience of the mother, or especially the doctor, should not come into play at all. Therefore, to be induced, or not to be induced, that is the question. The answer, ultimately, will depend on the beliefs of the mother, the beliefs of the doctor, and hopefully foremost, the health of the baby and the mother evaluated together. Technology has progressed a long way in our society, which has given many babies a chance at life whereas before the technology existed, they, and mostly likely the mother as well, might have died in labor. Unfortunately our society has taken that technology and used it for a purpose that is not its original intent: personal convenience. According to Wilson, the onset of labor, once considered a naturally occurring event, has become one of timing, control, and convenience for both obstetrical providers and expectant women, with nearly two thirds of all labor induction in the US now initiated for non-medical reasons (208). Is this the best practice for the baby and the mother? The induction of labor for non-medically necessary reasons is one of the most controversial issues in maternity care in this country today (Amis 16). The National Center for Health Statistics wrote that in 2002, the rate of labor induction in the United States had a 129% increase from 1989, the first year that data on induction was collected (Simpson and Thorman, 135). Wilson writes that because labor induction is a relative new event, data collection was not routinely collected for induction until 1989 (208). In the last few weeks of pregnancy, the mother’s body and the baby are preparing for the birthing process. These last weeks are vitally important for a mother and her baby, writes Lothian (43). For a first-time mother, the baby often “drops down” into the pelvis in the weeks before birth (Amis 16). This is part of the preparation for labor by the fetus. The last weeks also allow the baby to prepare for his or her entry in the world by allowing the baby to gain weight and strength, store iron, develop more coordinated sucking reflexes and swallowing ability, develop lung maturity further and also allow for important antibodies to be passed on from the mother to the infant (Lothian 44). Also according to Lothian, waiting for labor to begin on its own is the best way to determine if the baby is ready to enter the world and if the mother is ready to begin the birthing process (44). Normal term labor is the culmination of a sequence of interrelated hormonal shifts that are mediated primarily by the fetus, the placenta, the fetal membranes, and the mother’s endocrine system (Romano and Lothian 94). In an article by Amis, she states that researchers now believe that when a baby is ready for life outside his mother’s uterus, his body releases a tiny amount of a substance that signals the mother’s hormones to begin labor (16). When a woman goes into labor naturally, there are hormones called prostaglandins, which cause the cervix to soften and ripen. The quantity of prostaglandins released increases when the body is ready to deliver the baby (Moran and Kellem, p 32). There are also hormones released that stimulate uterine contractions to begin. According to Romano and Lothian, spontaneous onset of term labor signifies the fetus’ readiness to be born as well as the mother’s physiological receptiveness to the process (94). As the birth approaches, the mother may have a surge of stress hormones that may aid in the birth of the fetus (Romano and Lothian 95). All of these phenomena’s are completely natural and doctors and midwives agree that the natural onset of labor is the best way to deliver the baby. To define what exactly labor induction is: labor induction is the intentional initiation of uterine contractions before their spontaneous onset. According to ICEA (International Childbirth Education Association), labor induction is a process using various mechanical methods and chemicals to initiate uterine contractions before the onset of spontaneous labor with the goal of accomplishing a successful birth (31). According to Wilson, “an indicated induction is recommended as a therapeutic option when the benefits of birth outweigh the risks of continuing the pregnancy, as seen in certain high risk conditions with fetal compromise. Such conditions include eclampsia, preeclampsia (hypertension in the mother that is directly related to the pregnancy), premature rupture of the membranes, and suspected intrauterine fetal growth restriction” (208). Labor may be induced if it is more risky for your baby to remain inside your body than to be born. According to the American College of Obstetrics and Gynecologists, labor may be induced if: you water has broken and labor has not begun; your pregnancy is post term (more than 42 weeks), you have high blood pressure caused by your pregnancy, you have health problems such as diabetes that could affect your baby, you have an infection in the uterus, your baby is growing too slowly (Amis 16-17).When labor is brought on artificially, a number of events are not allowed to occur or occur prematurely. When labor is induced artificially, the drug Pitocin (oxytocin) is given intravenously in the hospital setting. Two main functions of prostaglandins are to regulate hormone activity and to contract the smooth muscle of the uterus (ICEA 36). Sometimes drugs called “ripening agents”, such as Cervidil or Cytotec, are given to soften the cervix and prepare it for labor (Amis 17). Pitocin is given after the cervix has ripened (ICEA 37). “Interfering with or replacing the natural hormones that orchestrate labor, birth, breastfeeding, and maternal attachment may have consequences that we do not yet understand,” writes Amis (19). As with all obstetric conveniences, there is growing evidence that the decision to induce for non-medically necessary reasons increases risks of interventions and complications, including, but not limited to: a longer labor compared to spontaneous labor, artificial rupture of membranes, significant discomfort, epidural anesthesia or increased need of other types of analgesia, maternal fever, hypotension, prolonged second stage of labor, operative vaginal birth, episiotomy, vacuum or forceps assisted vaginal birth, fetal heart changes, shoulder dystocia (where the baby’s shoulder gets stuck behind the mother’s pelvic bones), babies born with low birth weight, need for birth by cesarean section, need for admission to the Neonatal Intensive Care Unit (NICU), jaundice that required treatment and a lengthened hospital stay (Simpson and Thorman 135) (Amis 18) (Romano and Lothian 96). “Medical induction of labor also nearly doubled the risk of overall cases of amniotic-fluid embolism, and the association was stronger for fatal cases” (Kramer et al 1444). Because due dates are not an exact science, and there can be up to a two week error window for the actual due date, a medically induced baby at 38 weeks can actually only be 36 weeks old. This is one of the reasons that babies born after elective induction can have poor outcomes such as low birth weight or jaundice requiring treatment. They were accidentally born before they have reached full maturity, which is defined as reaching 37 completed weeks (Amis 8).Besides, adverse maternal outcomes, such as cesarean sections, there are other reasons that might warrant waiting for spontaneous onset of labor, such as the addition of escalating health care expenditures, including additional supply and labor costs, added lengths of hospital stay, and increased neonatal and maternal morbidity and mortality. Delivery with spontaneous onset of labor is significantly lower than the cost of delivering following induction, particularly those ending in a cesarean birth (Wilson 212). There is also the chance that the mother may have to an intravenous line and continuous electronic fetal heart monitoring. In many settings, the mother must stay in bed or very close to the bed, and this does not allow the mother to walk freely or change positions in response to labor contractions, possibly slowing the progress of labor. The mother may be unable to take advantage of a soothing tub bath or a warm shower to ease the pain of labor contractions. Artificially induced contractions often peak sooner and remain intense longer than natural contractions, increasing the mother’s need for pain medication (Amis 8). The afore mentioned natural interventions all help the mother to have an “easier” labor and to help the labor progress along at a natural rate. A tub bath or a warm shower can be relaxing to the mother and may even help with pain distraction. Being artificially induced removes the ability to utilize these techniques, which can lead to an increased need for pain relief in the form of medications.When it comes to the increased cost that is associated with elective induction of labor, Romano writes that women with induced labors were twice as likely to end up having their baby by cesarean delivery and in addition to this, their baby was more likely to need to be admitted to the Neonatal Intensive Care Unit (NICU). These factors resulted in a significantly high increase in the average cost of labor (53). The matter of convenience is often brought up as a reason to induce labor artificially. According to Amis, hospitals can provide extra nurses on during shifts when inductions are scheduled, the family can prepare for the birth by making work and family arrangements and the physician can schedule the birth on days and during hours that are convenient for them (17). However, the benefits must be weighed with the risks (Simpson and Thorman 135). What is not convenient about artificial induction is when the induction doesn’t go as planned: for example, the induction does not work and the mother is sent home only to return another day and try again, when there are delays in the hospital and when the induction leads to a cesarean birth, consequently leaving the mother to recover from major abdominal surgery rather than vaginal birth, or if the baby has breathing problems and/or has to be admitted to the Neonatal Intensive Care Unit (NICU) (Amis 17). What are the alternatives for the impatient healthy mother who wants to induce? Do chemical and mechanical interventions have to be used to bring about labor? No, labor can be induced by natural means, such as sexual intercourse or nipple stimulation. In ICEA’s statement, they state that sexual intercourse and nipple stimulation are natural methods that may help to stimulate contractions and improve the inducibility of the cervix. During the act of intercourse, prostaglandins are released into the bloodstream and may act on the uterus and the cervix. Prostaglandins are also contained in semen and may act directly on the cervix after ejaculation during intercourse. Nipple stimulation increases oxytocin that may also act on the uterus to start contractions (34). If these methods do not work, and the mother is still considering elective induction when there is not a medically necessary reason, then elective inductions for primiparous (first time) women should be offered with caution, particular for women with advanced maternal age (Wilson 213). Furthermore, studies have indicated that medical procedures, such as “epidural analgesia, induction, augmentation of first stage of labor, instrumental vaginal delivery and emergency caesarean section, and a prolonged labor” were all associated with a negative experience of labor and birth (Waldenstrom et al 22). Kramer writes that the “substantially raised risk in women whose labor was medically induced should be a cause for concern, in view of the increasing tendency for clinicians to induce labor, and especially for routine induction at term or after term” (1448). Both the mother and the practitioner should take all of these things into consideration when making the decision for elective induction. The mother should be fully informed of all the risks and possible complications, as well as the comfort techniques (walking, tub bathes, etc) that a medical induction does not always allow.Ultimately, waiting for labor to begin on its own increases the likelihood that you will have positive lifelong memories of your birth experience and decrease the possibility of complications for both you and the baby (Amis 6). Though I did not have all of the knowledge that is contained in the paper at that ten-week OB appointment, I knew in my heart that waiting for my baby to be born in her own timing was the best way to go. Instinctually, I felt that inducing my baby when there was no medical reason present was not what was best for her, and for me. Having reviewed the literature in the writing of this paper, along with taking birthing classes and reading various birthing books and non peer-reviewed journal articles, I can now say that my instincts were right on. As for the OB that wanted to induce me, I decided not to continue with her for the duration of my pregnancy and found a midwife who has treated me with much more respect for my wishes, for which I am truly grateful.

3 comments:

I went in for my weekly appt when I was 4 days past the due date. The dr said, "Why don't you go over to the hospital and get induced? I already have three ladies over there, and you could be number four." I remember feeling excited that things could finally start happening, but also hesitant. It was 5:00 p.m. and I asked if I could come back in the morning after a good night's sleep. He said no. I went to the hospital and got induced.

The pitocin didn't work. They increased it and increased it, but I wasn't dialating. The dr broke my water. I barely dialated to a 3 after 18 hours. Then, when the pitocin was maxed, the baby's heart rate plummeted and suddenly I had a cesarean. There were complications. My daughter had to go on oxygen in the nursery, while I was unable to leave my room. My husband and parents brought me pictures of her, but I couldn't go see her because of my condition. I received drugs to counteract my problems, and ended up with one that no one (including me) knew I was allergic to. I stopped breathing during a nap, and was saved by a nurse who "had a feeling" she should check on me.

Finally, nine hours after delivering, I was able to see my daughter. We were in the hospital for 5 days, and I had a difficult recovery afterward.

And all this happened so that my delivery would be more convenient for the doctor.

He didn't tell me anything about the risks of induction. I trusted him, and I paid for it. I have since switched doctors and become much more educated so that when things start happening too fast I will know what I want. I have read dozens of stories online about women who went through nearly the same thing I did. Induction is not a toy! We shouldn't be using it when it's not necessary!

Induction is induction, whether 'natural' or no. Birth is a natural process. As for:

"there are certainly a number of reasons where a woman should be induced for her safety and/or the safety of her child....being two weeks past the due date (greater than 42 weeks),..."

Who says that every woman's gestation is 40 weeks or 42 weeks? We are not all the same.

My LO was born 42+6 - I resisted some aggressive induction bullying from many hospital officials & staff. My son kicked off our labour & came into this world exactly as women have done for billions of years. I was 36 yrs old at delivery & he is my first child.

All women need to research what to expect from hospitals/drs & be prepared. Handing over your body & your child's life willingly to a doctor who knows little about natural birth is ignorant.

Research. Ask questions. Research more. Change providers. Say NO. Only you can get the birth you want. Find support & find someone familiar & skilled in natural birth that you can trust.